Accepted Abbreviations List

Transcription

1 Accepted Abbreviations List PURPOSE The purpose of the abbreviation list is to define recommended abbreviations that may be used in the documentation of patient care within the CCEMS system. Abbreviations are often used to facilitate and shorten written narratives. This is an acceptable practice as long as it is universally recognized and understood abbreviations are used. The following are medical abbreviations that are acceptable for use by EMS personnel in the CCEMSA region. In situations where an abbreviation is not listed and the provider intends to use the abbreviation more than once in the patient care report (PCR) the provider may spell out the complete term to be abbreviated with the abbreviation immediately following the term enclosed in brackets (i.e., () ). A. Unlisted abbreviations that are acceptable to use are the following: 1) Hospitals, clinics or other medical facilities: When abbreviating facilities use the first letter of each word of the proper title and only abbreviate the facility if it is already written in entirety on the PCR as the response location or destination. 2) Fire: When abbreviating a fire department FD must follow any letters used to abbreviate the city or municipality fire department. 3) Police: When abbreviating a police department or Police Officer response PD must follow any letters used to abbreviate the city or municipality police department. 4) Sheriff: When abbreviating a sheriff department or Sheriff Officer SO must follow any letters used to abbreviate the city or municipality sheriff department. B. Abbreviations acceptable to use on PCRs in the CCEMSA systems are listed as follows (see table below). Accepted Acceptable Abbreviations - Negative, without, decrease & And? Possible, questionable ^ or Change + Positive, with, increase < Less than = Equal > Greater than, F Female, M Male Fatality or Deceased 2nd, 3rd, etc. Used when describing order 5150 Danger to self, others, gravely disable with mental illness A/OX1,2,3,4 Alert, and (1) Oriented to Person, (2) Place, (3) Time, and (4) Event. Abd Abdomen Abr Abrasion ACE Angiotension converting enzyme AED Automated External Defibrillator A-fib Atrial Fibrillation A-flutter Atril Flutter AICD Automatic Internal Cardiac Defibrillator

2 AIDS Acquired immunodeficiency syndrome ALOC Altered level of consciousness ALS Advanced life support AM Morning AMI Acute myocardial infarction AOS Arrived On Scene AMS Altered mental status A-P Anteroposterior (front to back) APAP Acetaminophen APGAR Appearance, Pulse, Grimace, Activity, Respiration ASA Acetylsalicylic acid ASHD Arteriosclerotic heart disease AU Both Ears AV Atrioventricular BG Blood glucose BID Twice a day BLS Basic life support BM Bowel movement BP Blood pressure BVM Bag-valve-mask C/C Chief complaint C/o Complains of C1, C2 First, Second, etc., cervical vertebra CA Cancer or Carcinoma Ca++ Calcium CABG Coronary artery bypass graft CAD Coronary artery disease CALF CalFire* Cap Capsule CBC Complete blood count cc Cubic centimeter CCU Coronary care unit chemo Chemotherapy CHF Congestive heart failure CHP California Highway Patrol* cm Centimeter CNS Central nervous system CO Carbon monoxide CO 2 Carbon dioxide COPD Chronic obstructive pulmonary disease CP Chest Pain CPAP Continuous Positive Airway Pressure CPR Cardiopulmonary resuscitation CSF Cerebral spinal fluid CSMT Circulation, sensation, movement, temperature C-spine Cervical precautions applied CT or CAT Computed tomography (Scan) CVA Cerebrovascular accident D/C Discontinue DNR Do not resuscitate DOB Date of birth DOE Dyspnea on exertion DT Delirium tremens

3 DVT Deep vein thrombosis Dx Diagnosis ECG or EKG Electrocardiogram ED Emergency Department EDC Expected date of confinement EMS Emergency Medical Services EMT Emergency Medical Technician EMT-P Emergency Medical Technician - Paramedic ENT Ears, nose, throat ET or ETT Endotracheal tube ETCO 2 End-Tidal Carbon Dioxide (level) ETOH Ethyl alcohol FACTS Mnemonic for: Focus, Activity, Color, Time (onset and duration), and Supplemental history. Fe Iron FHR Fetal heart rate FHx Family history FR First responder or French sizing FTB Full-Thickness Burn Fx Fracture gm Gram g Gauge GB Gallbladder GCS Glasgow coma score GERD Gastroesophageal reflux disease GI Gastrointestinal GPA Gravida, Para, Abortus (i.e., G2, P1, A1) GSW Gunshot wound gtt(s) Drop(s) GYN Gynecology H 2 O Water HA Headache HBV Hepatitis B virus HCV Hepatitis C virus HIV Human immunodeficiency virus HPI History of present illness HSV-1, HSV-2 Herpes simplex virus type 1 or 2. HTN Hypertension Hx History I&O Intake & output IC Incident Commander ICP Incident Command Post ICU Intensive care unit IDDM Insulin-dependent diabetes mellitus IM Intramuscular IO Intraosseous IV Intravenous IVDU Intravenous drug use JVD Juggler vein distention K+ Potassium KED Kendrick Extrication Device Kg Kilogram (1000 grams) L1, L2 First, second, etc., lumbar vertebra LA Left atrim

4 Lat LBBB LLE LLQ LNMP LOC LP LR Lt LUE LUQ LV LVH LVN MAE MCC mcg MD MDMA Meds or Med meth mg MI ml mm MOI MRI MRSA MS MVC N/V/D NA Na+ NC NIDDM NKA NKDA NP or FNP NPA NPO NRB NRS NS NSAID NSR NTG O.D. O.S. O.U. O 2 OA OD OOS Lateral Left bundle branch block Left lower extremity Left lower quadrant Last normal menstrual period Loss of consciousness Lumbar puncture Lactated ringers Left Left upper extremity Left upper quadrant Left ventricle Left ventricular hypertrophy Licensed vocational nurse Moves all extremities Motor cycle collision Micrograms Medical Doctor 3,4-Methylenedioxymethamphetamine commonly known as Ecstasy Medications Methamphetamine Milligram (1/1000 gram) Myocardial infarction Milliliter (1/1000 liter) Millimeter (1/1000 meter) Mechanism of injury Magnetic resonance imaging Methicillin-resistant Staphylococcus aureus Morphine sulfate Motor vehicle collision Nausea, vomiting, diarrhea Nerve Agent (Tabun, Sarin, Soman, GF, VX) Sodium Nasal cannula Non-insulin dependent diabetes No known allergies No known drug allergies Nurse practitioner / family nurse practitioner Nasal pharyngeal airway Nothing by mouth Non-rebreather Numeric Rating Scale (1-10) (1= Low, 10=High) Normal saline Non-steroidal anti-inflammatory drug Normal sinus rhythm Nitroglycerin Right eye Left eye Both eyes Oxygen Osteoarthritis Overdose Out of Service

5 OPA OPQRST P PA PAC PASTE PASTMED PE PEA PERRL PFSH PID PM PMD PMH PN PND PNS POP PRN Pt PTA PTB PVC Q QH QID Resp. RR R/O RA RBBB RBC RLE RLQ RMCT RN ROM ROS RSV Rt RUE RUQ RV Rx S/S SA SAMPLE Oral pharyngeal airway Mnemonic for: Onset, Provoke, Quality, Radiates, Severity, and Time. Pulse Physician assistant Premature atrial contraction Mnemonic for: Progression, Associated chest pain, Sputum, Time, Exertion. Mnemonic for: Provocation, Associated chest pain, Sputum (color and amount), Time, Medications, Exertion, and Diagnosis. Physical examination or pulmonary embolism Pulseless electrical activity Pupils equal, round, and reactive to light Mnemonic for: Past, Family and Social History Pelvic inflammatory disease Afternoon Primary medical doctor Past medical history Pain Paroxysmal nocturnal dyspnea Peripheral nervous system Pain on palpation As needed Patient Prior to arrival Partial-Thickness Burn Premature ventricular contraction Every Each hour Four times a day Respirations Respiratory Rate Rule out Rheumatoid arthritis or Right Atrium Right bundle branch block Red blood cell Right lower extremity Right lower quadrant Refusal of medical care and/or transport Registered nurse Range of motion Review of symptoms Respiratory syncytial virus Right Right upper extremity Right upper quadrant Right ventricle Prescription Signs and symptoms Sinoatrial node Mnemonic for: Signs and symptoms, Allergies, Medications, Past history, Last oral intake, Events leading up to.

6 Sc or Sq Subcutaneous SL Sublingual SLUDGEM Mnemonic for: Salivation, Lacrimation, Urination, Defecation, Gastrointestinal distress, Emesis and Miosis. SNF Skilled nursing facility SOAP Mnemonic for: Subjective, Objective, Assessment, and Plan. SOB Shortness of breath SpO 2 Oxygen Saturation of peripheral Hgb START Simple Triage and Rapid Treatment Stat Immediately STB Superficial-Thickness Burn STD Sexually transmitted disease STEMI S-T elevation myocardial infarction Strep Streptococci (bacteria) Sx Symptoms T or Temp. Temperature T1, T2 First, second, etc., thoracic vertebra TA Traffic Accident Tab Tablet TB Tuberculosis TC Traffic Collision TIA Transient ischemic attack TID Three times a day TKO To keep open Trans Transport TTJI Transtracheal jet insufflation Tx Treatment Unk Unknown URI Upper respiratory infection UTL Unable to locate V/S Vital signs VF Ventricular fibrillation VT or V-Tach Ventricular tachycardia W/ or C_Bar With, C_Bar is a C with a line over. W/O or S_Bar Without, S_Bar is a S with a line over. WBC White blood cell WMD Weapon of mass destruction WNL Within normal limits X Times (used as multiplication sign) Y/O Year(s) old * The California Highway Patrol (CHP) and CalFire (CALF) have specific abbreviations because their response areas are in the entire CCEMSA region; hence they are not covered in section A of the listed abbreviations.